At the Hospital, a New Doctor Is In

By ABIGAIL ZUGER

Published: March 24, 1998

ANYONE who has been a patient or a visitor on an ordinary medical ward in an American hospital knows the usual routine. During the day a steady parade of residents, nurses, aides, students, therapists, nutritionists and social workers marches in and out of the room, but the doctor responsible for a patient's welfare is not among them.

Instead, the doctor usually makes a brief bedside appearance early in the morning or late in the evening. During standard work hours the doctor is in an office seeing outpatients. A sick patient in the hospital may receive phone calls or benefit from the occasional mad dash from office to hospital, but thoughtful face-to-face contact waits for after-hours.

Now the routine is changing in some American hospitals. Impelled by factors from insurers' impatience with a costly and inefficient system to doctors' frustrations with their inability to be in two places at once, a new species of doctor is evolving.

These new doctors are inpatient specialists, often called hospitalists, and they spend their workdays caring for hospitalized patients, taking over for patients' regular doctors.

From scattered beginnings less than a decade ago, the ranks of these specialists are growing fast. About 2,000 now practice across the country, with a new national organization lending structure to their role.

Studies consistently show that hospitalizations are 15 percent to 25 percent shorter when hospitalists care for patients, and hospital costs also go down 15 percent to 25 percent, said Dr. Robert M. Wachter, chief of medical service at Moffitt-Long Hospital in San Francisco. Dr. Wachter is an inpatient specialist and an expert on the new system.

Large health maintenance organizations are among the most enthusiastic users of inpatient specialists for these reasons, as well as for the fact that the specialists free doctors to see their full quota of outpatients on time.

But hospitalists are also among the most controversial figures on the medical scene. Critics argue that while they may promote efficiency and lower costs, their role threatens to undermine the traditional relationship between patient and doctor. If a doctor abandons a longtime patient at the hospital door, just when the patient needs the doctor most, they say, trust begins to crumble.

Critics also contend that valuable information about a patient's life and illnesses -- ranging from allergies and blood tests to preferences for end-of-life care -- may be lost as care is transferred from one doctor to another.

Advocates of the new system counter the criticisms. The Norman Rockwell doctor who takes solo care of a patient from womb to tomb has become a myth anyway, they say. Group practice already fragments a patient's care, while computerized data bases can insure that details about a patient's health are never lost.

Furthermore, statistics show that doctors admit far fewer patients to the hospital than they used to, and hospitalized patients are sicker than they used to be, forcing office doctors to maintain the difficult technical skills of caring for acutely ill patients even though they use them less and less often.

''In 1978 the average internist spent almost half of his or her time in the hospital, caring for 10 to 15 patients at a time,'' Dr. Wachter said, while now 10 percent of the doctors' time is spent in the hospital, where they may care for only one or two patients at a time.

''Once you're down below a certain number it may just make more sense on a lot of levels, both economics and quality, to have someone else take on that role,'' Dr. Wachter said. ''And as institutions and physicians are under more pressure to be efficient this becomes a very attractive way of doing it.''

Medically, patients seem to fare about as well under one system as the other, Dr. Wachter said. But often patients -- and doctors -- have distinct preferences.

In Springfield, Mass., Dr. Winthrop F. Whitcomb has been working as an inpatient specialist since 1994 in a group practice that provides round-the-clock care to patients in a community hospital. ''I loved it from the beginning,'' said Dr. Whitcomb, a co-founder of the new National Association of Inpatient Physicians. ''I was available for patients in the hospital and for their families through times of serious illness in a way that I wasn't when I was in the office setting.''

Over the years just the steady presence of a few familiar doctors in his hospital during the day has begun to improve the hospital's overall functioning, Dr. Whitcomb said.

''Because we're here all the time, when there's a systems problem we're more motivated to try to fix things,'' he said.

''We end up spending a lot of the day on the phone,'' he said, ''talking to the outpatient doctor and letting them know what's going on with the patient.''

But in Granite Hill, N.C., Dr. Sanford Guttler is a family doctor who continues to take care of his own patients in the hospital. ''Some of my colleagues continue to practice the usual way, and some have given up their hospital practice,'' he said. ''They're all happy and all think they're doing the right thing. The hospitalists in town are very busy. But I'm still staying the course.''

Dr. Guttler finds that patients are so grateful to see a familiar face in the hospital that he continues his hospital work, although every patient he admits extends his workday further into the night.